Table 3.

Studies of Weight Loss Interventions among People with ESKD and Obesity and Areas for Future Study

Citation	Study Participants	Intervention	Results	Potential Limitations & Questions For Future Research
Cook et al. (2008) [63]	66 participants with stage 4 CKD and stable or increasing weight (BMI 27.9–47.3 kg/m2): 22 received weight program intervention, 22 received standard care Intervention arm: 8 PD patients, 14 HD patients, 3 KT recipients, 19 in stage 2–4 CKD	A multidisciplinary weight management program with a low fat, reduced energy diet, individual exercise prescription and pharmacotherapy with Orlistat 120 mg total dissolved solids	73% of intervention group attended at least half of appointments Mean body weight reduced by 7.1 % from 102.9 kg to 95.7 kg (P<0.001) Reduction in BMI from 35.7 kg/ m2 at baseline to 33.2 kg/m2 at 12 months Waist circumference decreased by 12.9 cm (P<0.005) at 12 months Significant improvement in functional metrics	Attendance rates suggests needs to explore/address barriers to intensive behavioral interventions
Koshy, A. N., et al. (2008) [64]	Single-center case series 3 HD patients with obese BMI on KT waitlist	LAGB	Surgery enabled pts to lose sufficient weight loss to be eligible for KT No reported complications	Small sample size Potential selection bias
Freeman, C. M., et al. (2015) [65]	Prospective single center study of patients treated with LSG between December 2011 and January 2014 52 KT candidates Average preoperative BMI of 43.0 +/− 5.4 kg/m2 (range 35.8–67.7 kg/m2)	LSG	Weight loss with 6 months medical management before surgery significantly lower than 6 months following LSG (3.6% +/− 2.3% vs 37.6% +/−3.3%, p<0.0001) Mean BMI decreased from 43.0 kg/m2 pre-LSG to 36.4 kg/m2 post LSG No perioperative (<30 days) deaths In 25 months of follow up: three deaths, 2 within the first year 41% decrease in anti-HTN medications (p<0.001) 50% decrease in daily insulin dose (p<0.001) 6/52 participants received KT during follow-up	No information on patients who were deemed inappropriate for LSG-potential selection bias
Idorn, T., et al. (2016) [43]	Randomized placebo-controlled, double-blinded trial 20 patients with T2DM & ESKD (1:1 for liraglutide vs. placebo) 20 pts with T2DM & normal kidney function (1:1)	Liraglutide-titrated more slowly in ESKD participants than in participants with normal kidney function	Dose-corrected plasma trough liraglutide concentration at the final visit 49% higher (95% CI 6–109, P = 0.02) ESKD patients compared to patients with normal kidney function Body weight reduced similarly in both liraglutide-treated groups (from 91.1 +/− 4.9 to 99.7 +/− 5.2 kg) Adverse side effects more common in ESKD patients: nausea and vomiting	Findings support more testing of glucagon-like peptide-1 agonists for efficacy and tolerability in KT-eligible patients with obesity
Cohen J., et al. (2019) [46]	Retrospective cohort study 323,034 individuals in the United States without CKD, 1,694 patients with CKD, and 925 patients with ESKD who underwent bariatric surgery	LSG (primary surgery for ESKD pts) Gastric bypass (primary surgery for CKD and non-renal disease pts)	Post-operative mortality higher in ESKD ([OR] 11.59, 95% CI 6.71–20.04) but not among those with CKD ([OR] 1.00, 95% CI 0.32–3.11) Risk of 30-day reoperation compared to patients without CKD: CKD [OR] 2.25 (95% [CI] 1.45–3.51); ESKD [OR] 3.10 (95% CI 1.72–5.61) Increased risk of readmission, compared to patients without CKD: CKD [OR] 1.98 (95% CI 1.5–2.56); ESKD [OR] 2.97 (95% CI 2.05–4.31)	Different surgery types predominate based on CKD/ESKD status. Data source does not provide granular information on changes in nutrition and function after surgery Focus on short-term (30 day) outcomes
Cohen J., et al. (2019)[47]	Retrospective, single center cohort study 43 patients→pre-KT bariatric surgery 21 patients→post-KT bariatric surgery Propensity-score matched controls	Gastic bypass, SG, LAGB, Vertical banded Gastroplasty	Compared to matched controls, surgery pre- and post-KT associated with decreased graft failure HR among pre-KT surgery 0.31, 95% CI 0.29–0.33; HR among post-KT surgery 0.85, 95% CI 0.85–0.86 Post-KT mortality risk lower among pre- and post-KT surgery groups compared to matched controls	Potential unmeasured confounders, confounding by indication < 20% pre-KT surgery patients were dialysis-dependent at time of surgery-more study needed on outcomes in ESKD population
Bouchard, P., et al (2020)[66]	Retrospective cohort study 32 patients referred by transplant team fo surgical weight loss Average BMI 42.3 (5.2) kg/m2	LSG	One year median BMI change −9.8 (3.7) kg/m2 90 day complication rate: 3% (no deaths) One year after surgery: 63% listed for KT KT performed in 14 patients median of 8 months after surgery	No information on candidates who were not selected for surgical intervention.
Kassam A., et al. (2020)[48]	Retrospective single-center cohort study of patients referred for surgical weight loss by transplant program between 2011–2018 198 patients with ESKD 45 patients with CKD	LSG	Mean weight decreased from 129.4 +/− 26.8 kg to 105.0 +/− 22.3 kg. 71.7% patients achieved a BMI ≤40 kg/m2 (center transplant threshold)	Large loss to follow-up among those who did not receive surgery - of 499 patient referred to clinic, 256 patients did not receive SG (14→ medical therapy and 242 lost to follow-up) Reasons for loss to follow-up among those referred for surgical weight loss need further exploration

Abbreviations: BMI – body mass index; BS – bariatric surgery; HD – hemodialysis; KT – kidney transplantation; aHR – adjusted HR; OR – odds ratio; aOR – adjusted OR; CI – confidence interval; DDKT – deceased donor KT; CKD – chronic kidney disease; GBP – gastric bypass surgery; SG – sleeve gastrectomy; LSG - laparoscopic SG; RYGB – Roux-en-Y gastric bypass procedure; AGB - adjustable gastric banding; BPD–DS - biliopancreatic diversion–duodenal switch; ESKD - end stage kidney disease; RR – Relative risk; HR – Hazard ratio; SD – standard deviation;. GBD – gastric band surgery; T2DM – Type 2 DM.